Healthcare Provider Details

I. General information

NPI: 1639345580
Provider Name (Legal Business Name): PREM FORT MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/01/2008
Last Update Date: 06/24/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

501 6TH AVE S
ST PETERSBURG FL
33701-4634
US

IV. Provider business mailing address

501 6TH AVE S
ST PETERSBURG FL
33701-4634
US

V. Phone/Fax

Practice location:
  • Phone: 727-767-4313
  • Fax: 727-767-4391
Mailing address:
  • Phone: 727-767-4313
  • Fax: 727-767-4391

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080N0001X
TaxonomyNeonatal-Perinatal Medicine Physician
License NumberME123447
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: